"It didn't fit for me:" A qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans

Building resilience: A specialty clinic tailored to older adults at risk of violence and abuse

OBJECTIVE

Both structural (e.g., ageism) and personal (e.g., stigma) barriers hinder older adult's access to and engagement with mental health care). These barriers are particularly problematic for those vulnerable to interpersonal violence and abuse (e.g., due to social isolation). This study presents a quality improvement program aimed at older adults who have experienced significant stress events, particularly elder mistreatment, within a larger trauma specialty clinic. Leveraging home-based telemedicine, the clinic provides evidence-based psychotherapy tailored to older adults' needs.

METHODS

From 2021 through 2023, the authors retrospectively examined treatment initiation, engagement, completion, and clinical outcomes among 231 older adults age 60+ who reported trauma that met DSM-5 criterion A criteria for Post-traumatic Stress Disorder (PTSD), depression and other mental health comorbid conditions related to their traumatic event. The clinic uses an automated measurement-based care approach that facilitates Quality Improvement projects, allowing us to track treatment initiation, engagement, completion, and clinical outcomes for all patients.

RESULTS

The results indicated high treatment completion, high engagement with telemedicine-delivered interventions, and, most importantly, significant changes in clinical outcomes.

CONCLUSION

These findings highlight the importance of expanding telemedicine-based mental health services for older adults, challenging ageist norms, and prioritizing older adults' mental health needs by providing tailored services to this patient population.

Massed written exposure therapy delivered to veterans with posttraumatic stress symptoms on an acute inpatient mental health unit

Written exposure therapy (WET) is a brief, manualized trauma-focused treatment typically delivered in five individual weekly sessions. Given the brevity and effectiveness of WET, researchers have begun to focus on its delivery in a massed format. However, only one case study examining massed delivery has been published to date. As such, the objective of the current study was to examine the acceptability, feasibility, and preliminary effectiveness of massed WET among veterans with a trauma- and stressor-related disorder receiving care on an acute inpatient mental health unit. Veterans (N = 26) were assessed prior to, immediately after, and 1 month following massed WET. Most veterans found massed WET to be useful and acceptable. Recruitment and retention rates suggested that the treatment was feasible. Notably, the results revealed statistically significant reductions in overall posttraumatic stress symptoms, ηp 2 = .81, p < .001; depressive symptoms, ηp 2 = .71, p < .001; and functional impairment, ηp 2 = .42, p = .002. These findings add to a growing body of literature highlighting the preliminary effectiveness of WET across various settings, populations, and delivery formats. Limitations include the small sample size and uncontrolled design.

Current Research on Matching Trauma-Focused Therapies to Veterans: A Scoping Review

INTRODUCTION

Trauma-focused (psycho)therapies (TFTs) are often used to treat post-traumatic stress disorder (PTSD) of (military) veterans, including prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing. However, research thus far has not conclusively determined predictors of TFTs' success in this population. This scoping review's objectives are 1) to explore whether it is possible, based on currently available evidence, to match TFTs to veterans to maximize their outcomes, (2) to identify possible contraindications and adaptations of TFTs for this population, and (3) to identify gaps in the literature to guide future research.

MATERIALS AND METHODS

Standard scoping review methodology was used. "White" and "gray" literature searches resulted in 4963 unique items identified. Following title and abstract screening and full-text analysis, 187 sources were included in the review. After data extraction, a narrative summary was used to identify common themes, discrepancies between sources, and knowledge gaps.

RESULTS

Included publications most often studied CPT and PE rather than eye movement desensitization and reprocessing. These TFTs were at least partly effective with mostly moderate effect sizes. Attrition rates were slightly higher for PE versus CPT. There was variance in the methodological quality of the included studies.

CONCLUSION

The current literature on TFTs to treat PTSD in veterans contains several knowledge gaps, including regarding treatment matching. Future research should examine effectiveness of these treatments using multiple sources of outcomes, longer time periods, combination with other treatment, outcomes outside of PTSD symptoms (such as functioning), and resilience.

The Effectiveness of Imagery Rescripting Interventions for Military Veterans With Nightmares and Sleep Disturbances: A Systematic Review and Meta-Analysis

Imagery rescripting (ImRs) interventions have been found effective in improving sleep outcomes, although research has mostly focused on civilian, rather than military, samples. The aim of this review was to estimate the overall effectiveness of ImRs interventions for military veterans on primary outcomes of nightmare frequency and sleep quality. A systematic search was conducted in CINAHL, MEDLINE, PsycArticles, PsycINFO, Psychology and Behavioural Sciences Collection and the PTSDpubs database and was completed on 1 November 2021. Randomised controlled trials, nonrandomised trials and pre-post studies of ImRs interventions in veterans with sleep disturbances or nightmares were included. The methodological quality of the studies was assessed using the Effective Public Health Practice Project (EPHPP) tool, and meta-analysis was performed using Stata. Nineteen articles from 15 empirical studies were included in the review, and data from the 15 studies (involving 658 participants) were included in the meta-analysis. Meta-analysis findings indicated that ImRs interventions are associated with significant positive changes from pretreatment to posttreatment for nightmare and sleep quality. Significantly greater improvements were found in ImRs interventions compared to control groups for sleep quality (Hedges' g = -0.65, 95% CI [-1.20, -0.10]) but not for nightmare frequency (Hedges' g = -0.10, 95% CI [-0.34, 0.14]). Overall, the meta-analysis included a relatively small number of studies with poor methodological quality and considerable heterogeneity; therefore, findings should be cautiously interpreted. Further research should focus on veteran participants with larger samples and from a broader range of sources to determine effectiveness more confidently.

Examining the Veterans Health Administration whole health model of care within the context of posttraumatic stress disorder

The Veterans Health Administration's Whole Health system of care focuses on offering veterans holistic health approaches and tailoring health care to individual's goals and preferences. The present study assessed factors associated with Whole Health use and its potential benefits among veterans with posttraumatic stress disorder (PTSD) receiving Veterans Health Administration care. This cohort study used retrospective electronic health records combined with survey data (baseline, 6 months) from 18 Veterans Affairs Whole Health pilot implementation sites and compared patient-reported outcomes between veterans who used Whole Health services versus those who did not, among veterans with (n = 1,326) and without (n = 3,243) PTSD. Patient-reported outcomes assessed were pain (PEG), patient-reported outcomes measurement information system physical and mental health functioning, and a one-item global meaning and purpose assessment. Veterans with PTSD were more likely to have used Whole Health (38% vs. 21%) than those without PTSD. Veterans with PTSD who used Whole Health services experienced small improvements over 6 months in physical (Cohen's d = .12) and mental (Cohen's d = .15) health functioning. Veterans without PTSD who used Whole Health services experienced small improvements in physical health (Cohen's d = .09) but not mental health (Cohen's d = .04). Veterans with PTSD were frequently connected with Whole Health services even though implementation efforts were not explicitly focused on reaching this population. Results suggest Whole Health may play an important role in how veterans with PTSD engage with health care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive?

OBJECTIVE

Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity.

METHOD

The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial.

RESULTS

Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036).

CONCLUSION

Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.

How is trauma-focused therapy experienced by adults with PTSD? A systematic review of qualitative studies

BACKGROUND

Trauma-focused therapies (TFTs) are first-line treatments for posttraumatic stress disorder (PTSD). However, TFTs are under-utilised, partly due to clinicians' and patients' fear that TFT is too challenging or harmful. We review the qualitative studies on how adults with PTSD experience TFTs to enhance the understanding of user perspectives, therapeutic processes, and outcomes.

METHODS

PubMed, PsychINFO and PTSDPubs were searched between October 1st and November 30th, 2021. Study quality assessments were undertaken, and studies were analysed using a descriptive-interpretative approach. Nine studies were included.

RESULTS

The analysis resulted in the identification of four key domains, representing a temporal sequence of TFT stages: Overcoming ambivalence towards TFT, Experience of treatment elements, Motivation for dropout/retention, and Perceived changes post-treatment.

CONCLUSION

Although many participants reported high levels of distress and considered dropping out, only a minority did eventually drop out and most patients expressed that the hardships in therapy were necessary for PTSD improvement. Establishing a safe therapeutic environment and working with the ambivalence towards treatment was essential for retention. This review serves a dual purpose, to shed light on diverse TFT experiences found to be important for treatment satisfaction, and to elucidate common treatment patterns. The results can be used in preparing patients for therapy and in training TFT therapists. Studies had moderate to high quality, and more studies of experiences of TFT non-responders and dropouts in a non-veteran population are needed to further our understanding of the utility and limitations of TFTs.

Characterizing and Comparing Evidence-Based Psychotherapy Utilization Among Veterans with Co-occurring PTSD and Substance Use Disorder

Objective: The current study sought to describe a nationally representative sample of Veterans diagnosed with co-occurring PTSD and substance use disorder (SUD) who initiated and completed evidence-based psychotherapy (EBP) for PTSD, and explored whether completion rates differed by SUD subtype. Methods: Using electronic health record data from the Veterans Health Administration (VHA) Corporate Data Warehouse, Veterans with a dual diagnosis of PTSD and SUD who initiated either Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) between January 01, 2019 and July 16, 2019 were identified (N = 2,996). Logistic analyses were employed to determine whether there were differences in EBP completion rates among Veterans with an alcohol use disorder (AUD; n = 1,383) versus all other SUDs (n = 1,613). Results: On average, Veterans were 45 years old, and identified as male, White, and non-Hispanic. Logistic regression analyses revealed there was not a significant difference between Veterans with AUD only and other SUDs in the probability of completing EBP treatment, OR = 1.02, 95% CI =0.87, 1.17, p = 0.79. Conclusions: No differences in EBP completion rates were observed between SUD subtypes, indicating that EBPs for PTSD are tolerated well for individuals with various types of SUDs and may be offered as treatment options.

Effectiveness of prolonged exposure (PE) after implementation at a crime victim support centre

Background: Recent practice guidelines strongly recommend evidence-based psychotherapies (EBPs) as the first-line treatment for post-traumatic stress disorder (PTSD). However, previous studies found barriers to the implementation of EBPs and a relatively high dropout rate in clinical settings. After proving the efficacy of prolonged exposure (PE) in Japan [Asukai, N., Saito, A., Tsuruta, N., Kishimoto, J., & Nishikawa, T. (2010). Efficacy of exposure therapy for Japanese patients with posttraumatic stress disorder due to mixed traumatic events: A randomized controlled study. Journal of Traumatic Stress, 23(6), 744-750. https://doi.org/10.1002/jts.20589], we began implementing PE in a real-world clinical setting at the Victim Support Center of Tokyo (VSCT).Objective: We aimed to investigate the effectiveness and benefit of PE for crime-induced PTSD among VSCT clients and what causes dropout from treatment.Method: Of 311 adult clients who received counselling from clinical psychologists at VSCT due to violent or physical crime victimization from April 2008 through December 2019, 100 individuals received PE and participated in this study. Their PTSD symptoms were evaluated before and after treatment using the Impact of Event Scale-Revised and the Clinician-Administered PTSD Scale for DSM-IV.Results: A total of 93 participants completed PE and seven dropped out after six sessions or less. The completers group improved in PTSD symptoms with significant score differences between pre- and post-treatment in IES-R and CAPS-IV. Participants' symptoms did not exacerbate after treatment. Forty of 49 completers who left their workplace or college/school after victimization returned to work or study shortly after treatment. Compared to the completers, all dropout participants were women and younger. The majority were rape survivors, with significantly shorter intervals between victimization and treatment. The reasons for dropout were difficulty scheduling treatment between work/study schedules and manifestation of bipolar disorder or physical illness.Conclusions: PE can be implemented with significant effectiveness and a low dropout rate in a real-world clinical setting if advantages in the system and policies, local organizational context, fidelity support and patient engagement are fortified.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination

Prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) are effective, but some patients do not respond adequately, and dropout rates are high. Patients' beliefs about treatment and perceptions of treatment components influence treatment outcomes and may be amenable to change through intervention. The present study sought to identify beliefs and reactions to PE and CPT that differentiated completers who screened negative for a PTSD diagnosis after treatment (PTSD-), completers who screened positive for a PTSD diagnosis after treatment (PTSD+), and discontinuers who attended six or fewer sessions. Thematic analysis was used to identify themes in qualitative data collected via retrospective semistructured interviews with 51 completers (19 PTSD- after treatment, 32 PTSD+ after treatment) and 66 discontinuers of PE/CPT. Participants were demographically diverse veterans across service eras. Treatment-related beliefs and reactions differentiating these groups included perceived helpfulness of treatment, self-efficacy in engaging in treatment, anticipatory anxiety and concerns, interpretations of ongoing symptoms, and perceived consequences of treatment on functioning. Further, some patterns seemed to differ in early treatment sessions compared to during the active components of treatment. Findings point to potentially malleable targets that could be intervened upon to improve trauma-focused treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Clinician perspectives on technology-enhanced in vivo exposures during prolonged exposure therapy for PTSD

OBJECTIVE

To investigate clinicians' perceptions regarding the use of mobile technology tools during prolonged exposure (PE) therapy to allow for monitoring and enhancing in-vivo exposures (IVEs).

METHODS

Clinicians with training in PE therapy (N = 32; average of 9 years of practice) completed surveys asking about their perspectives on the utility of virtually attending IVEs with patients while simultaneously having access to real-time subjective and physiological data (i.e., heart rate, galvanic skin conductance) to guide exposure exercises and assure optimal stimulus engagement.

RESULTS

Findings showed clinicians to have a favorable view of applying technology devices and systems to enhance IVEs of PE therapy. Most clinicians (93.8%) believed that real-time monitoring of IVEs-particularly monitoring patients' subjective distress and completion of and duration of time in the IVE-would be useful and significantly enhance PE therapy.

CONCLUSION

The positive perceptions toward integrating technology into IVEs in this study have important implications for the development and implementation of technology-enhanced PE therapy. A mobile technology system that incorporates real-time indicators of engagement (i.e., both subjective and physiological) during IVEs and allows clinicians to review recordings of, or virtually accompany, patients during IVEs has the potential to innovate and transform PE and other exposure-based treatments. Clinicians also believed that technology-enhanced IVEs may help reduce early termination from PE.

Predictors of dropout in cognitive processing therapy for PTSD: An examination of in-session treatment processes

Dropout rates for treatments for adult posttraumatic stress disorder (PTSD) are high. Process research can reveal client factors during treatment that predict dropout. An observational coding system was used to code client processes in audio-recorded early sessions of cognitive processing therapy (CPT), a gold-standard treatment for PTSD. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET), with higher rates of dropout in CPT than WET (39.7% vs. 6.4%). Participants in this study were 53 treatment-seeking adults with PTSD who were in the CPT arm of the trial and completed the CAPS-5 at pretreatment and at least one session. Of these, 15 (28.3%) dropped out of CPT early (completing ≤9 sessions) and 38 (71.7%) completed treatment. Sessions were coded with an observational coding system on a four-point scale (0 = absent to 3 = high) for maladaptive trauma-related responses (overgeneralized beliefs, ruminative processing, avoidance), affective engagement (negative emotions, physiological distress), and adaptive processing (cognitive emotional processing). Binary logistic regressions showed that more physiological distress and cognitive emotional processing predicted lower dropout, whereas more avoidance predicted higher dropout. Negative emotion, ruminative processing, and overgeneralization were not significant predictors. These findings highlight potential early indicators of treatment engagement that could be targeted to reduce dropout and perhaps facilitate further therapeutic change.

"I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment

Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Veterans' reasons for dropping out of prolonged exposure therapy across three delivery modalities: A qualitative examination

Premature dropout from posttraumatic stress disorder treatment (PTSD) hinders treatment response. Studies have primarily used quantitative methodology to identify factors that contribute to Veterans' premature dropout, which has yielded mixed results. Qualitative methods provide rich data and generate additional hypotheses about why Veterans discontinue PTSD treatment. This study aimed to understand Veterans' reasons for dropping out of prolonged exposure therapy (PE) and to examine if there are differences in reasons for dropout between three delivery modalities: in-home, in-person (IHIP), office-based telehealth (OBT), or home-based telehealth (HBT). Twenty-two Veterans who dropped out of PE from a parent randomized clinical trial participated in individual qualitative interviews about potential contextual and individual factors related to discontinuation. Team-based coding was used to conduct open and focused coding. Themes were generated that described factors that influenced Veterans' dropout from PE and constant comparison was used to explore differences in reasons between the three modalities. Most Veterans had multiple reasons for dropping out and reasons were similar across delivery modalities with few differences. Practical barriers (e.g., scheduling difficulties), attitudes toward mental health providers and therapy (e.g., stigma), psychological and physical health factors (e.g., perceived worsening of symptoms, pain), and the therapeutic context (e.g., disliking aspects of PE) contributed to Veterans' decisions to drop out from PE. Veterans in OBT reported more types of practical barriers than Veterans in HBT and IHIP. These findings can help generate hypotheses about interventions that may promote engagement and future studies should continue to study how to reduce dropout. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Emotional freedom technique versus written exposure therapy versus waiting list for post-traumatic stress disorder: protocol for a randomised clinical MRI study

INTRODUCTION

The emotional freedom technique (EFT) is an acupuncture-based psychotherapy that combines tapping on acupoints with cognitive reframing. EFT has been previously shown to have potential for treating post-traumatic stress disorder (PTSD). However, further clinical evidence and underlying mechanisms of EFT are yet to be fully explored. This proposed clinical trial aims to examine the effect of EFT on patients with PTSD compared with the waitlist (WL) and active controls.

METHODS AND ANALYSIS

This study was designed as a randomised, assessor-blinded, three-arm clinical MRI study. A total of 120 eligible patients with PTSD will be recruited and randomised into EFT, written exposure therapy (WET) or WL groups. EFT and WET will be applied once a week for 5 weeks. For patients in the WL group, EFT will be performed after 12 weeks. PTSD symptoms, depression, anxiety, somatic symptoms and quality of life will be evaluated. Assessments will be conducted at baseline (week 0), post-treatment (week 6) and follow-up (week 12). Structural and functional brain images and recording videos of facial expressions to emotional stimuli will be obtained before and after treatment. Sixty participants without lifetime traumatic experiences will be enrolled as healthy controls. The primary objective of the study is to compare the change from baseline in the Clinician-Administered PTSD Scale after treatment (week 6) between EFT and WL groups and between EFT and WET groups.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Review Board of the Kyung Hee University Korean Medicine Hospital. The research findings will be shared at national and international conferences and will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service KCT0007360 https://cris.nih.go.kr/cris/search/detailSearch.do/21974.

If it's offered, will they come? Practical considerations when offering intensive PTSD treatment in an outpatient Veterans Affairs PTSD clinic

Evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are efficacious; however, treatment dropout remains high. The delivery of intensive EBPs for PTSD (i.e., sessions three times per week or more) and telemental health may address barriers impacting dropout. Current evidence for intensive EBPs comes primarily from programs specifically designed for this level of care. Therefore, the feasibility of delivering intensive EBPs for PTSD in traditional outpatient clinics remains unclear. The aim of this pilot study was to identify veteran level of interest in intensive treatment and explore the feasibility of delivering intensive treatment via telemental health in an outpatient PTSD clinic at a Veterans Affairs (VA) hospital. One provider offered intensive treatment to 14 veterans. Three of the veterans initiated intensive treatment and completed with benefit. Veteranand system-level barriers, as well as veteran preferences for initiating intensive therapy and suggestions for implementing intensive EBPs in a routine outpatient clinic, are discussed.

Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders

Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.

Trauma survivors' perceptions and experiences of prolonged exposure for PTSD at a psychology clinic

Background

Several trauma-focused treatments have been developed to treat post-traumatic stress disorder (PTSD). Yet there are limited studies on how trauma survivors perceive and experience trauma-focused treatments such as prolonged exposure therapy (PE) for PTSD, especially in low- and middle-income countries (LMIC).

Aim

The study aimed to explore the perceptions and experiences of trauma survivors receiving prolonged exposure therapy for PTSD and the general acceptability of PE for PTSD in a LMIC.

Setting

The study was conducted at a community psychology clinic in the Eastern Cape, South Africa.

Method

Using a qualitative method, seven adult trauma survivors who completed six sessions of brief PE for PTSD were interviewed. Thematic analysis was used to identify relevant themes and to understand how participants perceived and experienced PE for PTSD.

Results

The analysis yielded five themes, namely structure, obstacles, gender, exposure and experiences of recovery.

Conclusion

The findings suggested that participants perceived and experienced PE to be generally beneficial for the treatment of PTSD. Moreover, the study suggested that PE is an acceptable trauma therapy in a contextually diverse setting such as the Eastern Cape, South Africa. Overall, considering the evidence base of PE for PTSD, this study contributed to the literature on the acceptability of PE in a South African setting.

Contribution

The findings of the study are in keeping with the extant literature on how persons perceive and experience PE for PTSD. The findings of the study suggests that PE is an acceptable and beneficial trauma therapy for PTSD in a contextually diverse setting such as South Africa. It is recommended that large scale implementation studies be conducted to further investigate the effectiveness, feasibility, and acceptability of PE in South Africa.

'Undoing a knot': a qualitative study of massed 1-week Cognitive Processing Therapy

Introduction: Intensive or massed Cognitive Processing Therapy (CPT) for posttraumatic stress disorder (PTSD) has been found to result in significant PTSD symptom reductions. However, few studies to date have used qualitative approaches to systematically evaluate client reflections about massed treatment approaches for PTSD. To address this gap, the present study aimed to improve our understanding of trauma survivors' reflections following the completion of 1-week CPT.Method: We conducted semi-structured interviews with seven trauma survivors within 3-months of the completion of 1-week CPT. We used the scissor-and-sort technique to identify themes and subthemes in the qualitative data.Results: Using the scissor-and-sort technique, we generated five main themes and associated subthemes from the data. The main themes were: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations.Conclusion: Collectively, our results suggested that 1-week CPT was feasible and led to changes in PTSD symptoms and improved cognitive and affective coping skills.

Framework for Accurate Classification of Self-Reported Stress From Multisession Functional MRI Data of Veterans With Posttraumatic Stress

Background: Posttraumatic stress disorder (PTSD) is a significant burden among combat Veterans returning from the wars in Iraq and Afghanistan. While empirically supported treatments have demonstrated reductions in PTSD symptomatology, there remains a need to improve treatment effectiveness. Functional magnetic resonance imaging (fMRI) neurofeedback has emerged as a possible treatment to ameliorate PTSD symptom severity. Virtual reality (VR) approaches have also shown promise in increasing treatment compliance and outcomes. To facilitate fMRI neurofeedback-associated therapies, it would be advantageous to accurately classify internal brain stress levels while Veterans are exposed to trauma-associated VR imagery. Methods: Across 2 sessions, we used fMRI to collect neural responses to trauma-associated VR-like stimuli among male combat Veterans with PTSD symptoms (N = 8). Veterans reported their self-perceived stress level on a scale from 1 to 8 every 15 s throughout the fMRI sessions. In our proposed framework, we precisely sample the fMRI data on cortical gray matter, blurring the data along the gray-matter manifold to reduce noise and dimensionality while preserving maximum neural information. Then, we independently applied 3 machine learning (ML) algorithms to this fMRI data collected across 2 sessions, separately for each Veteran, to build individualized ML models that predicted their internal brain states (self-reported stress responses). Results: We accurately classified the 8-class self-reported stress responses with a mean (± standard error) root mean square error of 0.6 (± 0.1) across all Veterans using the best ML approach. Conclusions: The findings demonstrate the predictive ability of ML algorithms applied to whole-brain cortical fMRI data collected during individual Veteran sessions. The framework we have developed to preprocess whole-brain cortical fMRI data and train ML models across sessions would provide a valuable tool to enable individualized real-time fMRI neurofeedback during VR-like exposure therapy for PTSD.

Building strong therapeutic relationships quickly: The effect of the perceived working alliance on veterans' intensive PTSD treatment outcomes

Intensive treatment programs (ITPs) are successful at reducing posttraumatic stress disorder (PTSD) and depression symptoms in veterans. However, the role of the working alliance in the context of ITPs is largely unexplored. The purpose of this study was to examine veteran-rated working alliance with their individual cognitive processing therapy (CPT) provider as a predictor of changes in PTSD and depression symptoms as well as negative posttrauma cognitions in two unique ITP formats. Data were collected from 128 veterans who completed a 2-week ITP, involving 2 × individual CPT/day, as well as 73 veterans who completed a 3-week ITP, involving 1 × group CPT/day and 1 × individual CPT/day. Both ITPs included adjunctive wellness, skills, and psychoeducation services in addition to CPT. Linear mixed-effects models were used to determine whether changes in working alliance predicted changes in PTSD and depression symptoms. Stronger veteran-reported working alliance with their individual CPT therapist, most notably agreement on tasks, predicted significant reductions in both the 2-week and 3-week programs in PTSD (ps = .012 and .002, respectively) and depression symptoms (ps = .009 and .007, respectively) and negative posttrauma cognitions (ps = .009 and .016, respectively). These results highlight the importance of veterans' perceived working alliance with their individual treatment therapists in ITPs. Results suggest that a strong working alliance that is meaningful for treatment outcomes can be developed quickly despite the brevity of this intensive treatment format. Future research should examine ways to facilitate the development of a strong working alliance prior to or as early as possible in ITPs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Relationship and Alliance Formation Processes in Psychotherapy: A Dual-Perspective Qualitative Study

Objective

To explore how therapists and clients act dyadically to establish a therapeutic relationship during the first five sessions of psychotherapy. The study aimed to identify both relational facilitative and hindering processes occurring in routine care.

Methods

Using the method ‘interpersonal process recall’ (IPR), we videotaped the third and fifth session of 12 psychotherapy dyads, and conducted video-assisted interviews with each therapist and client separately. In total, the data material consist of 47 IPR interviews. Data were analyzed using a thematic approach.

Results

The analysis process revealed two main groups. The first group consisted of dyads with a positive relational outcome, and the second group consisted of dyads with a troubled or frail relational outcome. During the initial phase of therapy, clients described feeling overwhelmed by fear and shame. Positive relational development occurred when these emotions were successfully accommodated and replaced with a growing sense of safety with the therapist. However, the relationship became troubled when the client experienced an increase in shame and/or fear during the first sessions. When forming a therapeutic relationship, it is vital that the client experience the therapist as genuine and skilled, and that the therapist is able to engage and connect deeply with the client on a person-to-person level. The article further provides a discussion on how these dyadic experiences align with the working alliance and real relationship, and how the two consolidate during the first sessions of psychotherapy.

Conclusion

The current study explored the complex relational processes underlying the formation of the therapeutic relationship. Core aspects of the real relationship are prerequisites to forming a collaborative working alliance in which both therapist and client are actively engaged. Facilitating a positive relationship is crucial in the early phase of psychotherapy, and therapists can actively identify and repair ruptures at this time.

Do early responders and treatment non-responders offer guidance to make CPT group a more effective treatment?

BACKGROUND

Treatment dropout has been problematic with evidence-based treatments for posttraumatic stress disorder (PTSD), including cognitive processing therapy (CPT). This study sought to evaluate whether CPT group contributed to symptom improvement among treatment completers and non-completers.

METHODS

Sixty-one Iraq and Afghanistan combat Veterans self-selected CPT group or treatment as usual (TAU) forming a convenience sample. Defining treatment completion as attending at least nine sessions: 18 completed treatment, 20 dropped-out (DOs); 20 completed TAU, 3 lost to TAU follow-up.

RESULTS

Multiple Regression revealed significant pre-post-treatment improvement, the Clinician-Administered PTSD Scale (CAPS-IV, F(5, 40.1) = 2.53, p = 0.0436). Reviewing DOs' last available PTSD Checklist-Military Version scores before leaving treatment, six achieved clinically significant improvement of >10 points; seven a clinically reliable change of 5-10 points.

CONCLUSION

These findings highlight that CPT group may be effective at reducing trauma-related symptoms among treatment completers and dropouts and point to the utility of a clinical definition of good treatment end-state.

Treatment dropout among veterans and their families: Quantitative and qualitative findings

BACKGROUND

Psychotherapy noncompletion rates for veterans and their families are high. This study sought to (a) measure noncompletion rates of such patients at a university-based treatment center, (b) compare veteran and family member attrition rates, (c) identify dropout predictors, and (d) explore clinicians' perspectives on treatment noncompletion.

METHOD

Using quantitative and qualitative approaches, we analyzed demographic and clinical characteristics of 141 patients (90 military veterans; 51 family members) in a university treatment center. We defined dropout as not completing the time-limited therapy contract. Reviewing semistructured interview data assessing clinicians' perspectives on their patients' dropout, three independent raters agreed on key themes, with interrater coefficient kappa range .74 to 1.

RESULTS

Patient attrition was 24%, not differing significantly between veterans and family members. Diagnosis of major depression (MDD) and exposure-based therapies predicted noncompletion, as did higher baseline Hamilton Depression Rating Scale (HDRS) total scores, severe depression (HDRS > 20), lack of Beck Depression Inventory weekly improvement, and history of military sexual trauma. Clinicians mostly attributed noncompletion to patient difficulties coping with intense emotions, especially in exposure-based therapies.

CONCLUSION

Noncompletion rate at this study appeared relatively low compared to other veteran-based treatment centers, if still unfortunately substantial. Patients with comorbid MDD/PTSD and exposure-based therapies carried greater noncompletion risk due to the MDD component, and this should be considered in treatment planning. Ongoing discussion of dissatisfaction and patient discontinuation, in the context of a strong therapeutic alliance, might reduce noncompletion in this at-risk population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same?

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (β = -4.80; HDI₉₅: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.

Women Veterans' Attrition from the VA Health Care System

PURPOSE

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care.

METHODS

A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.

RESULTS

Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.

CONCLUSIONS

Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.

The beginning of the end: A comparison of treatment completers and early dropouts in trainee-provided time-limited Cognitive Behavioral Therapy

About one in five clients drops out of treatment prematurely. Premature termination has been found to correlate with patient, therapist, and treatment factors, as well as complex interpersonal processes, including ruptures in the therapeutic alliance. This study examines the therapeutic alliance using a qualitative approach to patient-, therapist-, and observer-based data. The sample includes five trainee therapists, each of whom worked with one patient who terminated after the first or second session, and one who completed a cognitive-behavioral therapy protocol. The session(s) preceding premature termination in the drop case and the corresponding session(s) in the completer case were examined. Rupture resolution process was prevalent in both groups, though confrontation ruptures seemed more prevalent with completers and withdrawal ruptures were more clinically impactful with dropouts. Therapist awareness of process and responsiveness or contribution to rupture were identified as potential factors contributing to patient retention.

Interactive Motion-Assisted Exposure Therapy for Veterans with Treatment-Resistant Posttraumatic Stress Disorder: A Randomized Controlled Trial

BACKGROUND

Veterans with posttraumatic stress disorder (PTSD) tend to benefit less from evidence-based treatments than other PTSD populations. A novel virtual reality and motion-assisted exposure therapy, called 3MDR, provides treatment in an immersive, personalized and activating context.

OBJECTIVE

To study the efficacy of 3MDR for veterans with treatment-resistant PTSD.

METHOD

In a randomized controlled trial (n = 43) 3MDR was compared to a non-specific treatment component control group. Primary outcome was clinician-rated PTSD symptoms at baseline, after 3MDR, and at the 12-week and 16-week follow-up (primary end point). Intention-to-treat analyses of covariance and mixed models were applied to study differences between groups at the end point and over the course of intervention, controlling for baseline scores.

RESULTS

The decrease in PTSD symptom severity from baseline to end point was significantly greater for 3MDR as compared to the control group, with a large effect size (F[1, 37] = 6.43, p = 0.016, d = 0.83). No significant between-group difference was detected in the course of PTSD symptoms during treatment when including all time points. The dropout rate was low (7%), and 45% of the patients in the 3MDR group improved clinically. The number needed to treat was 2.86.

CONCLUSIONS

In this trial, 3MDR significantly decreased PTSD symptoms in veterans with, on average, a history of 4 unsuccessful treatments. The low dropout rate may be indicative of high engagement. However, a lack of significant differences on secondary outcomes limits conclusions that can be drawn on its efficacy and underlines the need for larger phase III trials. These data show emerging evidence for 3MDR and its potential to progress PTSD treatment for veterans (Dutch Trial Register Identifier: NL5126).

A Theory of Planned Behavior Scale for Adherence to Trauma-Focused Posttraumatic Stress Disorder Treatments

Evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy and prolonged exposure (CPT/PE), greatly reduce suffering for veterans, but many veterans fail to complete treatment. Developing a theory-based understanding of adherence is necessary to inform interventions to improve treatment retention. We developed and tested a series of scales applying the theory of planned behavior (TPB) to CPT/PE adherence. The scales were administered in mailed surveys as part of a larger mixed-methods study of veteran adherence to PE/CPT. Surveys were sent to 379 veterans who were initiating CPT/PE across four U.S. Veterans Affairs (VA) hospitals and 207 of their loved ones. Subsequent session attendance and homework compliance were coded via a review of electronic medical records. We examined item-level characteristics, factor structure, and the convergent and discriminant validity of the resultant scales. The findings support four subscales: two related to attitudes (i.e., Treatment Makes Sense and Treatment Fits Needs), one related to perceived behavioral control over participation (i.e., Participation Control), and one related to perceived family attitudes about CPT/PE participation (i.e., Subjective Norms). Scale validity was supported through significant associations with theoretically relevant constructs, including intentions to persist in CPT/PE, rs = .19-.38; treatment completion, rs = .21-.25; practical treatment barriers, rs = -.19 to -.24; and therapeutic alliance, rs = .39-.57.

Within-treatment clinical markers of dropout risk in integrated treatments for comorbid PTSD and alcohol use disorder

BACKGROUND

Integrated interventions for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are effective, but many patients prematurely drop out from treatment. Little is known about within-treatment risk factors for dropout, limiting the ability during therapy to identify patients at risk for attrition.

METHODS

We examined measures assessing PTSD (PTSD Checklist for DSM-5; PCL-5), alcohol use (Substance Use Inventory; SUI), and patient satisfaction (Client Satisfaction Questionnaire; CSQ-8) as potential within-treatment markers of dropout risk, administered to 110 veterans in a randomized clinical trial of integrated exposure therapy versus integrated coping skills therapy for comorbid PTSD + AUD. Hierarchical Cox proportional hazard models with dropout status as the endpoint assessed effects of PCL-5, SUI, and CSQ-8 on dropout risk, and whether effects differed by treatment modality.

RESULTS

A significant interaction between treatment and changes in alcohol use was observed (HR = 2.86, p =  .007), where between-session alcohol use was positively associated with dropout hazard rate for those receiving integrated exposure therapy (HR = 2.34, p =  .004), but not coping skills therapy (HR = 0.73, p =  .19). Specifically, an increase of one drink consumed per day in the interval since last assessment (typically 2-3 weeks) was associated with a 5-fold increase in dropout hazard rate.

CONCLUSIONS

The findings provide preliminary evidence of detectable within-treatment markers of dropout during integrated treatment for PTSD + AUD. Study of within-treatment indicators proximal to dropout may help identify at-risk patients and inform timely strategies to boost retention.

Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review

Some post-traumatic stress disorder (PTSD) patients do not benefit from imaginal exposure therapy. One possible approach to reach such patients are virtual trauma interventions. Herein, a qualitative scoping review was conducted. Different types of virtual trauma exposure interventions were identified. For each type of virtual trauma exposure interventions it was examined in detail: (1) which in sensu trauma exposure approach serves as therapeutic framework, how it was transferred into virtual reality, and if it was manualized; (2) which hardware and software were used; (3) whether the influence of spatial and social presence on the efficacy of virtual trauma interventions have been measured, and (4) whether the efficacy of virtual trauma interventions for PTSD patients having imagination difficulties was evaluated. These research questions were analyzed qualitatively. Accordingly, an extensive literature search was conducted using the databases Web of Science, PsycINFO, LIVIVO, PTSDpubs, and PubMed for scientific articles published between January 2013 and July 2020. Only studies aimed to reduce PTSD symptoms using virtual trauma interventions were included. The literature search was not limited to a specific study design, treatment/intervention method, or a minimum sample size. Eighteen studies were identified, which reported three different virtual trauma intervention approaches, namely, virtual reality exposure therapy (VRET), multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), and action-centered exposure therapy (ACET). Seven randomized controlled trials (RCTs), two pilot studies, and one case study were focused on VRET; while two RCTs, one pilot study, and three case studies focused on 3MDR, and two case studies on ACET. Regarding the first research question (1), the results show that VRET is based on prolonged exposure, aiming for a virtual re-creation of the patient's traumatic recounting. Several treatment protocols exist for VRET. 3MDR is based on eye movement desensitization and reprocessing, aiming to reduce the patient's avoidance behavior. In 3MDR patients walk toward individualized trauma-related symbolic images in a cave automatic virtual environment (CAVE). One treatment protocol exists for 3MDR. ACET is based on the inhibitory learning theory, aiming for active interactions with a virtual trauma-associated environment to alter the anxiety structure through new secondary inhibitory learning. One treatment protocol exists for ACET. For the second research question (2), the results indicate that all VRET studies used head-mounted displays (HMDs) with a virtual version of the Iraq/Afghanistan or the World Trade Center attacks, while 3MDR studies utilized two different versions of a CAVE with personalized trauma-related images, and the ACET studies used HMDs with virtual street scenarios. For the third research question (3), the results demonstrate that the influence of spatial or social presence on the efficacy of virtual trauma interventions was not examined in any of the included studies. Similarly, for the fourth research question (4), the results show that empirical evidence for the efficacy of virtual trauma interventions on PTSD patients having imagination difficulties was lacking. Therefore, such empirical studies are needed to fill these research gaps.

Perceived treatment processes and effects of interactive motion-assisted exposure therapy for veterans with treatment-resistant posttraumatic stress disorder: a mixed methods study

Background: A novel intervention, Multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), aims to reduce avoidance and improve engagement for patients with posttraumatic stress disorder (PTSD) who did not sufficiently respond to previous treatments. It has been found to effectively reduce PTSD symptoms for veterans with treatment-resistant PTSD. Symptomatic measures alone might not capture all treatment effects, and addition of qualitative outcomes may provide deeper understanding of treatment processes and treatment-induced changes. Objective: To study the perspectives of veterans with treatment-resistant PTSD on 3MDR treatment processes and effects and explore the relation of their experiences to PTSD symptom improvement. Method: A convergent parallel mixed methods design was applied. For the qualitative part, open-ended question interviews were conducted until data saturation was reached (N = 10). Thematic analysis, rooted in grounded theory, was performed. Quantitative data included pre- to posttreatment responder status based on a structured clinical interview for PTSD. Results: Treatment processes endorsed by the veterans were engaging, regulating distress, feeling supported, facing traumatic memories, allowing emotions, associating, and disengaging from trauma. In terms of effects, veterans reported positive changes following 3MDR, including openness, new learning, self-understanding, closure, and reintegration. High comparability across themes was observed for responders and non-responders, except for the themes closure and reintegration, which were reported more often or more in depth by responders. Conclusions: Veterans indicated 3MDR treatment processes that complied with its aims of breaking through avoidance and increasing engagement, thereby facilitating traumatic memory retrieval and processing. However, this did not necessarily translate into PTSD symptom improvement for all veterans. Walking towards trauma-related pictures was highlighted as unique component of 3MDR and connected to specific treatment processes and effects. Positive changes following 3MDR were experienced outside the domain of PTSD symptom improvement, implicating that 3MDR may beneficially impact veterans beyond symptom changes alone.

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury: design and methodology of a pilot study

BACKGROUND

Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy.

METHODS

We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.

DISCUSSION

We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.

TRIAL REGISTRATION

NCT04280965 .

Changes in alcohol use, PTSD hyperarousal symptoms, and intervention dropout following veterans' use of VetChange

OBJECTIVE

Veterans of Iraq and Afghanistan conflicts report high rates of drinking, PTSD, and low rates of treatment engagement. Web interventions may help address unmet treatment need; unfortunately, little is known regarding outcomes or adherence to these interventions. In this study, we examined VetChange treatment outcomes and downstream effects of alcohol reduction on PTSD symptoms and intervention dropout rates over six months.

METHOD

Participants included 222 veterans (77.5% men, 78.3% White) between 22 and 57 (mean age = 36.02, SD = 7.19). All VetChange users completed a brief alcohol assessment and received personal feedback, then received full access to intervention content including psychoeducation; motivational and cognitive-behavioral modules for relapse prevention, goal-setting, social support, stress, anger, and sleep management; and mood and drink tracking. Veterans completed self-report measures of alcohol use and PTSD symptoms at baseline, one, three, and six months.

RESULTS

Alcohol use dropped by 43% over six months, p < .001, with the largest decrease occurring within the first month. Greater alcohol reduction in the first month predicted higher subsequent PTSD hyperarousal severity. Over half (52.3%) dropped out by month one, followed by 12.2% and 37.6% by months three and six. Hyperarousal symptoms, hypervigilance specifically, but not alcohol use predicted subsequent intervention dropout.

CONCLUSION

These results highlight the importance of attending to the association between alcohol use and PTSD symptom change in web-based interventions for veterans. The fact that hyperarousal symptoms were associated with elevated risk for intervention dropout signifies the need for online intervention refinement aimed at tailoring content to time-varying symptom presentations.

Equine-Assisted Therapy for Veterans with PTSD: Manual Development and Preliminary Findings

INTRODUCTION

Equine-assisted therapy (EAT) for post-traumatic stress disorder (PTSD) has attracted great interest despite lacking empirical support, a manual, and a standardized protocol. Our team of experts in EAT and PTSD developed an eight-session group EAT treatment protocol for PTSD (EAT-PTSD) and administered it to two pilot groups of military veterans to assess initial effects.

MATERIALS AND METHODS

We describe the development of the treatment manual, which was used with two pilot groups of veterans. Protocol safety, feasibility, and acceptability were assessed by reported adverse events, treatment completion rates, and self-rated patient satisfaction. Preliminary data on PTSD, depressive, and anxiety symptoms and quality of life were collected pretreatment, midpoint, post-treatment, and at 3-month follow up.

RESULTS

No adverse events were recorded. All patients completed treatment, reporting high satisfaction. Preliminary data showed decreases in clinician-assessed PTSD and depressive symptoms from pre to post-treatment and follow-up (medium to large effect sizes, d = .54-1.8), with similar trends across self-report measures (d = 0.72-1.6). In our pilot sample, treatment response and remission varied; all patients showed some benefit post-treatment, but gains did not persist at follow-up.

CONCLUSIONS

This article presents the first standardized EAT protocol. Highly preliminary results suggest our new manualized group EAT-PTSD appears safe, well-regarded, and well-attended, yielding short-term benefits in symptomatology and quality of life if unclear length of effect. Future research should test this alternative treatment for PTSD more rigorously.

Evidence-based psychotherapy trends among posttraumatic stress disorder patients in a national healthcare system, 2001-2014

BACKGROUND

Although evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) were implemented starting in 2005 in the veterans health administration (VHA), the largest national healthcare system in the U.S., the rate of initiation (uptake) and prevalence of these treatments in each calendar year have not been determined. We aimed to elucidate two metrics of EBP utilization, uptake and prevalence, following implementation.

METHODS

Cohort study of Iraq and Afghanistan veterans in VHA (N = 181,620) with a PTSD diagnosis and ≥1 psychotherapy-coded outpatient visit from 2001 to 2014. Using natural language processing techniques, annual and cumulative uptake and prevalence rates from 2001 to 2014 were calculated for each of the two EBPs for PTSD, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy.

RESULTS

Annual uptake of CPT increased during most years, reaching a maximum of 11.1%. Annual uptake of PE showed little change until 2008 and then increased, reaching a maximum of 4.4%. The annual prevalence of CPT increased throughout the study, reaching a maximum of 14.6%. The annual prevalence of PE increased to a maximum of 5.0% in 2010, but then flattened and declined. Annual uptake of minimally adequate CPT increased a to maximum of 5% in 2014. Annual uptake of minimally adequate PE increased to a maximum of 1.2% in 2010. The cumulative prevalence of CPT was 19.9% and cumulative prevalence for PE was 7.5%.

CONCLUSIONS

Access to EBPs for PTSD modestly increased for Iraq and Afghanistan veterans after nationwide implementation efforts. Further expanding the reach to veterans is critical, given low rates of minimally adequate EBPs for PTSD.